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                        <h2 class="title">Managed Care</h2>
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								<span>Key Concepts</span>
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									<h3>Overview</h3>
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										<p>Managed care is a set of contractual and management methods partnered with health care providers and medical 
										facilities in providing medical services at reduced costs and improved quality care. It is a set of techniques 
										and concepts used in financing and delivering health-related services to members enrolled under the system. 
										It is believed to reduce health care expenditures by offering the ability to acquire significant lower costs 
										by contracting for large volumes of physician, laboratory, pharmacy and hospital services.</p>

										<p>The Managed Care segment covers organizations that provide Healthcare Protection Services (Insurance). 
										The nature of such business involves benefits in terms of funding coverage when availing to an array of 
										healthcare related benefit types (e.g. Medical, Pharmaceutical, Dental, Behavioural and Mental Health, etc.).  </p>

										<p>The rise for both healthcare and employee benefits costs has been the primary trigger for the development 
										of managed care.  As traditional corporate health insurance, Medicare and Medicaid were open-ended entitlement 
										systems, managed care gave way to physicians, hospitals and insurers to benefit from increased spending.
										Due to cost shifting, businesses started on turning to contractors to stabilize expenses, even it means having
										to face client complaints. Managed care provided an organizational structure to the nation in controlling
										health care delivery to improve efficiency and limit the total health care expenditures. </p>

										<p>The Healthcare Benefits Management business started during mid-1800 period in a form where workers are paid 
										for lost wages in cases where an injury was work related (Essential of Managing Healthcare, 2007, Kongstvedt; 
										Healthcare USA, 2012). As the industry matures, it had subscribed into a standard insurance model wherein 
										coverage are extended further to other incidental health expenses outside work. Though adopting some concepts of 
										insurance, the healthcare is quite peculiar as normally insurance covers for low probability incidents while in 
										the case of healthcare insurance some areas of coverage maybe discretionary and predictable. This approach was 
										pioneered and popularized by Blue Cross enabling the extension of the access (mostly up to middle class) to
										expensive healthcare benefits. </p>

										<p>The rising enrolment as a result of Blue Cross' offering had driven enrolment upwards and from which had 
										been very difficult to control. By 1970s, the industry made an introduction to Health Management Organization (HMO).
										HMO integrates healthcare providers and insurers - such organization employs or manages the health services 
										providers and thus providing better control, fraud deterrence, and proper costing. Today the operating model 
										to that of a Managed Care (HMO) Organization had been used as a standard for Healthcare related insurance. </p>
										
										<p>Managed care basically differs from the conventional medical practice in that the transaction between 
										the physician and the patient is monitored and controlled by a manager.  In Managed Care Organization (MCO), 
										contracts with hospitals and physicians are made by insurance companies, creating a network of providers. This 
										type of network is known as the Preferred Provider Organization (PPO) which limits the services received by 
										insurance beneficiaries to doctors and hospitals that are within the network only. To ensure the control of costs 
										and services given to recipients, gatekeeping is done by requiring referrals or authorization from physicians,
										acting as managers, for special services such as hospitalization and surgery. Financial risks are also controlled
										through capitation, which involves paying for the number of people enrolled rather than the number of services 
										offered, and withholds, wherein a percentage of the amount paid for a particular medical service goes into a 
										withhold pool to help compensate for any unforeseen extra volume above the projected expenditures. </p>
										
										<p>Other cost control methods used by MCOs in controlling cost and utilization are second opinion, precertification, 
										pre-admission testing, concurrent review, database profiling, intensive care management, generic substitution, 
										discharge planning, retrospective review and audits. In second opinion, the findings and recommendations by 
										the initial doctor must be reviewed and affirmed by a second doctor before treatment is done. Before conducting
										special medical treatment and procedures, the need for such procedures are evaluated and approved by the 
										insurance company in advance. This process is involved in precertification. On the other hand, in pre-admission
										testing, reviews and tests are done on the patient prior to admission. This is to avoid longer days the patient
										has to stay in the hospital. In concurrent review, a case control nurse does regular evaluations for the 
										authorization of continued or extended in-patient admission and other additional procedures. Database profiling 
										involves the use of graphs and charts, which show the number of services used by every 1,000 patients for 
										each physician or hospital, in identifying whatever unbalanced utilization of services there is. In intensive 
										case management, any projected case to amount to more than $10,000 is monitored and managed by a nurse in
										the insurance company. Generic substitution involves providing less expensive generic drug as prescription 
										to patients over a brand-name drug, taking into account that FDA considers the two as equivalent. In 
										discharge planning, facilitation of immediate home transfer is done by a social worker where he/she meets 
										with the patient and patient's family. An evaluation is done in retrospective review after discharge of the 
										patient from the hospital to ensure the avoidance of payment accountability for any unnecessary medical services.
										Audits are done by a representative from the insurance company to warrant the delivery of all billed services. </p>
										
										<p>Generally, managed care plans are categorized as Health Management Organization (HMO) Plans, Preferred 
										Provider Organization (PPO) Plans, and Point of Service (POS) Plans. In HMO, members pay a fixed monthly 
										fee, regardless of the expenses to be incurred for necessary medical services in a particular month. 
										Members are allowed to use the services and facilities offered by health care providers within the HMO 
										network only for the cost to be covered. If outside the network, members are obliged to pay the bill. In PPO, 
										enrollees are authorized to stay within the network of health care providers. The company makes contracts with 
										a network of health care providers, typically under a fee-for-service agreement. Outside of the network, the 
										enrollees pay for the fees. PPO members pay for the medical services as they were given, instead of paying ahead.
										The member is being reimbursed by the PPO insurance company with the expenses incurred for the services,
										excluding any co-payments made. In other instances, the insurance company directly pays the amount to the
										physician after the bill was submitted, and the member covers for the co-payment amount he/she has made. 
										Fundamentally, POS plans function with combined characteristics of HOM and PPO plans. Usually, POS plans 
										function similarly with HMO plans as you are allowed to choose a physician within the network who manages
										your medical services.  The use of providers outside of the network is allowed, however the beneficiary has
										to cover for the expenses given. As the name itself suggests, every time the beneficiary needs medical
										services (the period or "point of service"), he/she has the option to accept care within the network allowing 
										to be managed by the primary care physician (PCP) or accept care outside of the network on his/her own terms
										without a recommendation from the PCP. How you and your family access and receive health care and the cost
										you have to pay out every time you receive care may be determined by the type of managed care plan you have. </p>
										
										</br></br></br>
										
										<h3>References</h3>
										
										<strong>Managed Care - The HMO Revolution (Chapter 10)</strong>
										</br><strong>Health Care Economics</strong>
										</br><strong>Financing Health Care (Chapter 7)</strong>
										</br><strong>Health Care USA </strong>
										</br></br>
										
										<p><strong>Managed Care</strong>
										</br><a href="http://en.wikipedia.org/wiki/Managed_care" target="_top">
										http://en.wikipedia.org/wiki/Managed_care </a></p>
										
										<p><strong>Managed Care Organization (MCO) Law & Legal Definition </strong>
										</br><a href="http://definitions.uslegal.com/m/managed-care-organization-mco/" target="_top">
										http://definitions.uslegal.com/m/managed-care-organization-mco/</a></p>
										
										<p><strong>Managed Care </strong>
										</br><a href="http://legal-dictionary.thefreedictionary.com/Managed+Care+Organization" target="_top">
										http://legal-dictionary.thefreedictionary.com/Managed+Care+Organization</a></p>
										
										<p><strong>Managed Care - Understanding Managed Care</strong>
										</br><a href="http://healthinsurance.about.com/od/understandingmanagedcare/a/managed_care_overview.htm" target="_top">
										http://healthinsurance.about.com/od/understandingmanagedcare/a/managed_care_overview.htm</a></p>
										
										<p><strong>Types of Managed Care Plans </strong>
										</br><a href="http://www.aarphealthcare.com/insurance/managed-care-plans.html" target="_top">
										http://www.aarphealthcare.com/insurance/managed-care-plans.html</a>
										</br><a href="http://www.healthychildren.org/English/family-life/health-management/health-insurance/Pages/Types-of-Managed-Care-Plans.aspx" target="_top">
										http://www.healthychildren.org/English/family-life/health-management/health-insurance/Pages/Types-of-Managed-Care-Plans.aspx</a>
										</br><a href="http://ocw.jhsph.edu/courses/managedcare/PDFs/MC%20FACT%20SHEET.pdf" target="_top">
										http://ocw.jhsph.edu/courses/managedcare/PDFs/MC%20FACT%20SHEET.pdf</a></p>
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															<h3 id="sidebar-content-header">Revenue Streams</h3>
															<p>Related organizations derive the generation of their revenues from the following:</p>
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																<li>Healthcare Premium</li>
																<li>Treasury</li>
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															<h3 id="sidebar-content-header">Healthcare Premium</h3>
															<p>Premiums are periodic collections done to members in order for them to be enrolled and be covered for a certain 
															benefit package. Depending on the organization (and other regulatory or legislative interventions), rates of 
															premiums may vary based on a function of age, existing health conditions, desired coverage, and the like. 
															With any pre-need organization, premiums are factored in based on actuarial calculation on risks presented 
															by an entity that is covered. In the case of healthcare, the financial risks are spread over a "community" 
															with varying risk level and therefore should be off-set to a level that would most likely sustain operations 
															and yield profits.</p>
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															<h3 id="sidebar-content-header">Treasury</h3>
															<p>A major activity also for Managed Health services to remain profitable is the prudent allocation of any 
															financial reserves (i.e. excess funds available after an ample allocation to funds to cover benefit claims) 
															to various investment options. </p>
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															<h3 id="sidebar-content-header">Medical </h3>
															<p>Professional treatment for any injury or illness.</p>
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														<div id="pharmaceutical">
															<h3 id="sidebar-content-header">Pharmaceutical </h3>
															<p>Guided services on the provision of drug/medicinal treatment aimed to eliminate or reduce the patient's
															symptoms on certain medical conditions, or to slow down the progress of a disease, or simply to prevent 
															a disease and the symptoms involved. </p>
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														<div id="dental">
															<h3 id="sidebar-content-header">Dental </h3>
															<p>Services offered for the teeth, may it be cleaning, whitening, x-ray, fillings, tooth extraction and oral surgery. </p>
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														<div id="ambulatoryServices">
															<h3 id="sidebar-content-header">Ambulatory Services </h3>
															<p>Services provided to patients outside of the medical facility premises. Usually given to patients who 
															have returned home after receiving medical diagnosis or treatment without having to stay overnight in the 
															hospital. Outpatient services included are preventive, diagnostic and treatment.</p>
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														<div id="mentalService">
															<h3 id="sidebar-content-header">Mental Healthcare Service </h3>
															<p>Services rendered which involves the examination and treatment for people having problems on their psychological 
															state. Services may include individual therapy, group therapy, social care and medication evaluation.</p>
														</div>														
														<div id="introBenefitCoverage">
															<p>A variety of services such as physician visits, prescription drug coverage, emergency care and more are offered 
															as part of the benefit coverage for managed care plans. Calculations are done on the included coverage, co-payments 
															and other options depending on the services covered by the network and the type of managed care plan the insured 
															has. A limit on the amount of services that may be provided is reinforced. It could be through the maximum cost 
															or the allowable number of days that can be covered for a particular service or treatment. To aid in the 
															identification of anomaly of the utilization of services, including any potential abuse or fraud, accumulators 
															are used as counter of similar events or procedures which have occurred. To determine whether claims are consistent 
															with a regular pattern of utilization, they are compared to a set of accumulators. The following are terms involved 
															in the benefit coverage calculation for managed care plans:</p>
															<ul>
																<li>Deductible </li>
																<li>Out-of-pocket (OOP) </li>
																<li>Co-payment/ Co-pay </li>
																<li>Co-insurance  </li>
																<li>Benefit Cap </li>
																<li>Maximum Benefit Limit (MBL) </li>
															</ul>
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															<h3 id="sidebar-content-header">Deductible</h3>
															<p>This is the amount of money that the beneficiary must pay for health care expenses before the insurance company
															will cover for the claim. Depending on the plan, it may have both per individual or family deductibles. Separate 
															deductibles for specific services can be applied for plans. For instance, a plan can have a hospitalization 
															deductible per admission. Deductibles may differ if health care services are received within the approved network 
															of providers or if received from service providers outside of the network. Deductibles prevent people from making 
															claims when the health care costs from services acquired are relatively small, leaving the company more time and
															financial resources to handle more costly claims. Deductible payments are useful for keeping the cost of insurance 
															low. Generally, lower deductibles are associated with higher premiums.</p>
														</div>				
														<div id="oop">														
															<h3 id="sidebar-content-header">Out-of-pocket (OOP) </h3>
															<p>This refers to the fee paid by the beneficiary of medical services directly to the health care service provider 
															at the time of service. Out-of-pocket payments are expenses for health care services that are not reimbursed by 
															the insurance company. This includes deductibles, coinsurance and copayments for services that are covered plus 
															all other costs for services not covered.</p>
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														<div id="copay">
															<h3 id="sidebar-content-header">Co-payment/Co-pay </h3>
															<p>This refers to the amount of money that the beneficiary is required to pay for health care services, 
															usually specified as a fixed amount or as a flat fee, in addition to what is covered by the insurance company.
															The rest of the reimbursement is shouldered by the insurer. There can be separate copayment for different services. 
															In some cases, plans require that a deductible be made first for specific services before application of copayments.</p>
														</div>
														
														<div id="coInsurance">
															<h3 id="sidebar-content-header">Co-insurance </h3>
															<p>This is a form of cost sharing between health insurance plan provider and the insured. This requires the 
															insurance beneficiary to pay for the agreed percentage of all health care expenses after payment for the deductible
															amount, if there is any, was made. After making payments for any deductible amount and coinsurance, the insurance 
															company is responsible for the reimbursement of the benefits that are covered up to the allowable limit. Coinsurance 
															rates may vary if the services are received from approved service providers within the network or if services are
															from providers outside of the network.  Furthermore, rates may vary for different types of services.</p>																												
														</div>
														
														<div id="benefitCap">
															<h3 id="sidebar-content-header">Benefit Cap </h3>
															<p>This is the total amount that the insurer will reimburse for all covered health care services for a specific 
															coverage period. Also referred to as the lifetime or day limitation of an insurance policy.</p>																											
														</div>
														
														<div id="mbl">
															<h3 id="sidebar-content-header">Maximum Benefit Limit (MBL) </h3>
															<p>This refers to the maximum amount reimbursed by the insurer for all the health care services made by the 
															insured while covered under the health care plan. Plans may have a yearly or lifetime maximum benefit limit.</p>
															
															</br>
															<strong>BENEFIT COVERAGE MODELS </strong>	
															<p>Standard practices for controlling and limiting benefit coverage are implemented (mostly based on country as 
															these are regulated and controlled normally by Government Entities). The following are the currently identified
															benefit coverage models:</p>						
															
															</br>
															<strong>Maximum Benefit Limit (Philippine Setting)</strong>
															</br></br>
															
															<img class="img-responsive center-block" id="image" src="../img/MBLPhilippines.png" />
															</br>
															
															<p>Managed Care organizations in the Philippines set-up and control their benefit coverage using Maximum Benefit
															Limits. In this model, a benefit cap is placed per condition or sickness from which all covered healthcare 
															services in relation to a person's condition are paid for by the Managed Care Organization until such time 
															that the MBL has been exhausted. Note that such limits would reset if a healthcare service is with respect to 
															another condition (unless the condition is caused by a pre-existing condition). Depending on the plan, the 
															coverage may vary based on categories (e.g. In-patient, Out-patient), service type (e.g. Dental, Rehabilitative, 
															Pharmaceutical, Medical, etc.), and for some even place additional conditions and restrictions for specialized
															services (e.g. Fertility, Immunization).</p>
															
															</br>
															<strong>Accumulator Based (USA Setting)</strong>
															</br></br>
															
															<img class="img-responsive center-block" id="image" src="../img/accumulatorUSA.png" />
															</br>
															
															<p>The US Healthcare Insurance System make use of various accumulators to control consumer behavior 
															(minimize abuse by financially involving consumers on related services). In this model, Deductibles are placed
															wherein a Member pays in full all related expenses until such a point that a Deductible Limit is met and 
															from which the Insurance Coverage benefits will kick-in (point of coverage).</p>
															
															<p>During said point of coverage, the Member would continue to participate (mostly a smaller portion of a
															Healthcare Service) through a co-insurance and co-pay setting. Co-pays are usually a marginal fixed cost amount. 
															Co-insurance usually is a portion of the service cost.</p>
															
															<p>A member continues to pay co-insurance until such time that an Out-Of-pocket (OOP) limit has been met. 
															OOP or "Stop Cost", the full amount of a covered service will be paid for by the provided (with the exemption 
															of co-pay). During this point, all benefits covered should be paid for until such time that a benefit cap has
															been met and from which all financial liabilities will be reverted back to the consumer.</p>
														</div>
														
														<div id="ppo">
															<h3 id="sidebar-content-header">Preferred Provider Organization (PPO)  </h3>
														
															<p>In PPO, enrollees are authorized to stay within the network of health care providers. The company makes 
															contracts with a network of health care providers, typically under a fee-for-service agreement. Outside of 
															the network, the enrollees pay for the fees. PPO members pay for the medical services as they were given, 
															instead of paying ahead. The member is being reimbursed by the PPO insurance company with the expenses 
															incurred for the services, excluding any co-payments made. In other instances, the insurance company directly 
															pays the amount to the physician after the bill was submitted, and the member covers for the co-payment 
															amount he/she has made. </p>																													
														</div>
														
														<div id="hmo">
															<h3 id="sidebar-content-header">Health Management Organization (HMO) </h3>
															
															<p>In HMO, members pay a fixed monthly fee, regardless of the expenses to be incurred for necessary medical
															services in a particular month. Members are allowed to use the services and facilities offered by health 
															care providers within the HMO network only for the cost to be covered. If outside the network, members 
															are obliged to pay the bill. </p>	

															<p>HMO has two types namely: </p>

															<ul>
																<li>Individual Practice Association (IPA)/Network Model HMOs - a type of managed care health insurance 
																plan that contracts a group of physicians and/or solo private practitioners to handle the patients.
																Usually, participating IPA physicians contract with more than one managed care plan.</li>
																<li>Staff/Group Model HMOs - under a staff/group model HMO, physicians are hired either directly 
																by the HMO or by a separate physician group formed to care for the HMO patients.</li>
															</ul>
														</div>
														
														<div id="pos">
															<h3 id="sidebar-content-header">Point of Service (POS) </h3>
															
															<p>Fundamentally, POS plans function with combined characteristics of HOM and PPO plans. Usually, POS 
															plans function similarly with HMO plans as you are allowed to choose a physician within the network who 
															manages your medical services.  The use of providers outside of the network is allowed, however the 
															beneficiary has to cover for the expenses given. As the name itself suggests, every time the beneficiary 
															needs medical services (the period or "point of service"), he/she has the option to accept care within 
															the network allowing to be managed by the primary care physician (PCP) or accept care outside of the network
															on his/her own terms without a recommendation from the PCP. </p>																													
														</div>
														
														<div id="gatekeeping">
															<h3 id="sidebar-content-header">Gatekeeping  </h3>
															
															<p>This is done by requiring referrals or authorization from physicians, acting as managers, for special 
															services such as hospitalization and surgery to ensure the control of costs and services given to recipients. </p>																													
														</div>
														
														<div id="capitation">
															<h3 id="sidebar-content-header">Capitation </h3>
														
															<p>Method used to control financial risks, which involves paying for the number of people enrolled rather 
															than the number of services offered. </p>																													
														</div>
														
														<div id="withholds">
															<h3 id="sidebar-content-header">Withholds </h3>
															
															<p>Method used to control financial risks, wherein a percentage of the amount paid for a particular medical 
															service goes into a withhold pool to help compensate for any unforeseen extra volume above the projected expenditures. </p>																													
														</div>
														
														<div id="secondOpinion">
															<h3 id="sidebar-content-header">Second opinion </h3>
															
															<p>Under second opinion, the findings and recommendations by the initial doctor must be reviewed and affirmed by a
															second doctor before treatment is done. </p>																													
														</div>
														
														<div id="precertification">
															<h3 id="sidebar-content-header">Precertification </h3>
															
															<p>In precertification, before conducting special medical treatment and procedures, the need for such procedures are 
															evaluated and approved by the insurance company in advance. </p>
														</div>
														
														<div id="preAdmissionTesting">	
															<h3 id="sidebar-content-header">Pre-admission Testing  </h3>
															<p>Reviews and tests are done on the patient prior to admission. This is to avoid longer days the patient 
															has to stay in the hospital. </p>
														</div>
														
														<div id="concurrentReview">
															<h3 id="sidebar-content-header">Concurrent review  </h3>
															
															<p>A case control nurse does regular evaluations for the authorization of continued or extended in-patient 
															admission and other additional procedures. </p>
														</div>
														
														<div id="databaseProfiling">
															<h3 id="sidebar-content-header">Database Profiling  </h3>
															
															<p>Involves the use of graphs and charts, which show the number of services used by every 1,000 patients 
															for each physician or hospital, in identifying whatever unbalanced utilization of services there is. </p>
														</div>
														
														<div id="caseManagement">
															<h3 id="sidebar-content-header">Intensive Case Management </h3>
															
															<p>Any projected case to amount to more than $10,000 is monitored and managed by a nurse in the insurance company. </p>
														</div>	

														<div id="genericSubstitution">
															<h3 id="sidebar-content-header">Generic Substitution </h3>
															
															<p>Involves providing less expensive generic drug as prescription to patients over a brand-name drug, taking 
															into account that FDA considers the two as equivalent.</p>
														</div>
														
														<div id="dischargePlanning">
															<h3 id="sidebar-content-header">Discharge Planning </h3>
															
															<p>Facilitation of immediate home transfer is done by a social worker where he/she meets with the patient and patient's family. </p>
														</div>
														
														<div id="retrospectiveReview">
															<h3 id="sidebar-content-header">Retrospective Review </h3>
															
															<p>Evaluation is done after discharge of the patient from the hospital to ensure the avoidance of payment accountability 
															for any unnecessary medical services. </p>
														</div>		

														<div id="audits">
															<h3 id="sidebar-content-header">Audits </h3>
															
															<p>Are done by a representative from the insurance company to warrant the delivery of all billed services. </p>
														</div>	
														
													</div>
												</div>
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								<div class="section_header">
                                    <h3>Organization</h3>
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																<a href="https://sites.google.com/a/pointwest.com.ph/hmc-domain-website/industrysegments-managedcare/introduction" target="_top">Introduction </a>	
															</div>
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															<div class="panel-heading">
																<a href="https://sites.google.com/a/pointwest.com.ph/hmc-domain-website/industrysegments-managedcare/board-of-directors" target="_top">Board of Directors </a>	
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																<a href="https://sites.google.com/a/pointwest.com.ph/hmc-domain-website/industrysegments-managedcare/key-management" target="_top">Key Management Positions </a>
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																<a href="https://sites.google.com/a/pointwest.com.ph/hmc-domain-website/industrysegments-managedcare/medical-management" target="_top">Medical Management Committees </a>
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															<div class="panel-heading">
																<a href="https://sites.google.com/a/pointwest.com.ph/hmc-domain-website/industrysegments-managedcare/organization-references" target="_top">References </a>
															</div>
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												<div class="col-xs-12 col-sm-9">
													<h3 id="sidebar-content-header">References</h3>
													
													<p><strong>Managed Care: the US Experience</strong>
													</br><a href="http://www.who.int/bulletin/archives/78(6)830.pdf" target="_top">
													http://www.who.int/bulletin/archives/78(6)830.pdf </a></p>
													
													<p><strong>McGraw-Hill Concise Dictionary of Modern Medicine. © 2002 by The McGraw-Hill Companies, Inc. </strong>
													</br></p>
													
													<p><strong>Mosby's Medical Dictionary, 8th edition. © 2009, Elsevier </strong>
													</br><a href="http://medical-dictionary.thefreedictionary.com/managed+care+organization" target="_top">
													http://medical-dictionary.thefreedictionary.com/managed+care+organization</a></p>
													
													<p><strong>Elements of Management and Governance Structure by Peter Kongstvedt, MD  </strong>
													</br><a href="http://samples.jbpub.com/9781449653316/Chapter3.pdf" target="_top">
													http://samples.jbpub.com/9781449653316/Chapter3.pdf</a></p>
													
													<p><strong>Managed Care - What It Is and How it Works (3rd Edition) by Peter Kongstvedt, MD  </strong>
													</br><a href="http://books.google.com.ph/books?id=vD-Ofdc6UW0C&pg=PA46&lpg=PA46&dq=managed+care+organization+board+of+directors&source=bl&ots=zmUwOtJGbs&sig=Pc_usBQGwTtVouibUWlAfrrbptM&hl=en&sa=X&ei=7MHwUsX9PMeeiAeYq4CICw&sqi=2&ved=0CE8Q6AEwBA#v=onepage&q=managed%20care%20organization%20board%20of%20directors&f=false" target="_top">
													http://books.google.com.ph/books?id=vD-Ofdc6UW0C&pg=PA46&lpg=PA46&dq=managed+care+organization+board+of+directors&source=bl&ots=zmUwOtJGbs&sig=Pc_usBQGwTtVouibUWlAfrrbptM&hl=en&sa=X&ei=7MHwUsX9PMeeiAeYq4CICw&sqi=2&ved=0CE8Q6AEwBA#v=onepage&q=managed%20care%20organization%20board%20of%20directors&f=false</a></p>
													
													<p><strong>Chapter 11 - Managed Care </strong>
													</br><a href="http://www.aw.com/info/phelps/Chapter11.pdf" target="_top">
													http://www.aw.com/info/phelps/Chapter11.pdf</a></p>
													
													<p><strong>Managed Care Strategies  </strong>
													</br><a href="http://books.google.com.ph/books?id=OOsfPoGqNKoC&pg=PA422&lpg=PA422&dq=managed+care+organization+board+of+directors&source=bl&ots=xoe-pZ_BNz&sig=1djlRrgo7Bg0AtxcHwhPLSnhMnA&hl=en&sa=X&ei=7MHwUsX9PMeeiAeYq4CICw&sqi=2&ved=0CDwQ6AEwAQ#v=onepage&q=managed%20care%20organization%20board%20of%20directors&f=false" target="_top">
													http://books.google.com.ph/books?id=OOsfPoGqNKoC&pg=PA422&lpg=PA422&dq=managed+care+organization+board+of+directors&source=bl&ots=xoe-pZ_BNz&sig=1djlRrgo7Bg0AtxcHwhPLSnhMnA&hl=en&sa=X&ei=7MHwUsX9PMeeiAeYq4CICw&sqi=2&ved=0CDwQ6AEwAQ#v=onepage&q=managed%20care%20organization%20board%20of%20directors&f=false</a></p>
								
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								<div class="section_header">
									<h3>Function</h3>
								</div>
								<div class="row feature">
									<div class="col-sm-12">
										<p>A managed care organization (MCO) is an organization that provides health care services to the beneficiaries through 
										managed care health plans. The MCO is affiliated with a network of service providers such as physicians, laboratories,
										hospitals and other health-related institutions and practitioners. It usually delivers health care services through a 
										defined medical service provider and defined products and services. </p>

										<p>In some instances, managed care beneficiaries are required to choose or are designated with a primary care physician (PCP).
										The beneficiary contacts the PCP whenever there is a need for any health care service. Treatment can be done by the 
										PCP or he/she may refer the insured to a medical practitioner within the network. Outside the network, insurance
										coverage is not applicable, unless a PCP referral is obtained.</p>
										</br>
										
										<img class="img-responsive center-block" src="../img/multipartyrelationship.png" />
										</br>
										
										<p>Figure 5 illustrates the relationship exhibited by the parties involved in health care servicing transactions. 
										The MCO acts as the middleman between buyers (consumers) and sellers (service providers). It facilitates transactions 
										and exchanges between buyers and sellers ensuring the satisfaction of both parties as seen and measured by outcomes 
										over cost. Moreover, consumers access health care providers for the benefit packages offered to them through MCOs since 
										their affiliation with MCOs is directed by their employers/sponsors.</p>

										<p>Diversification in network configurations has been orchestrated by the product selection offered by managed care 
										plans. Nowadays, health plans are comprised with multi-product health benefits firm which offer a wide selection of
										products with finer and better quality meeting consumers’ taste and preference.  As shown in Figure 5, health plan 
										providers effectively create and offer an array of products that target to match the purchasers' preference when it 
										comes to benefits, financing and delivery system designs. Moreover, managed care organizations negotiate with different 
										provider networks or network configurations in terms of payment methods and participation for the availability of
										products and services. This product diversity results in the increased level of complexity for both providers and 
										consumers. Gone are those days of only high or low option product offered by insurers or only single product without
										any out-of-network benefits from HMOs.</p>
										
										</br></br></br>
										
										<h3>References</h3>
										
										<p><strong>Markets at Risk-Current and Future Challenges in a Managed Care Marketplace</strong>
										</br><a href="http://aspe.hhs.gov/health/reports/hurley/markets.htm" target="_top">
										http://aspe.hhs.gov/health/reports/hurley/markets.htm </a></p>
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